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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_927_Библиотеки_им_академика_М_И_Перельмана.pdf
P
F
C
ODUCTION
INTR
espite recent advances in medical therapy, approximately 25% to
D
30% of patients with ulcerative colitis (UC) will need surgery for
refractory colitis or colitis-associated neoplasia. For these patients,
a total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is
the standard surgical option. During the past four decades, IPAA has
been constantly shown to reduce the risk of UC-associated neoplasia
and to improve quality of life. On the other hand, construction of
an IPAA is technically demanding, with mechanical, inammatory,
and functional sequelae that can be minimized by good technique,
but not completely avoided. Pouchitis and irritable pouch syndrome
are the most common inammatory and functional disorders of the
pelvic pouch and will be discussed in this chapter.
POUCHITIS
ouchitis is inammation of an ileal pouch. It can be specic (with an
P
identiable cause) or nonspecic. Cumulative frequencies of pouchitis aer IPAA range from 23% to 46% over 10 to 11 years of follow-up.
In a small clinical drug trial of prophylaxis of pouchitis with a probiotic agent, the incidence was 40% within the rst 12 months aer
ileostomy closure.
ETIOLOGY AND
t is intriguing that pouchitis occurs almost exclusively in patients
I
with underlying UC and is rarely seen in patients with a pouch who
have familial adenomatous polyposis, suggesting causative factors in
common with UC that may be genetic and/or systemic. In general,
pouchitis results from alterations in commensal luminal microora
(dysbiosis) and subsequent abnormal mucosal immune response in
genetically susceptible hosts.
Genetic Factors
mmunogenetic studies have shown that polymorphisms in genes
I
such as those coding for interleukin-1 receptor antagonist NOD2/
CARD15 or a combined carrying of TLR9-1237C and CD14-260T
alleles are associated with an increased risk of chronic pouchitis.
PATHOGENESIS
P P
Bo Shen
o be associated with dysbiosis, sometimes pathogenic bacteria,
t
viruses, and fungi can be found in a subset of patients, especially
those who present with constitutional symptoms (e.g., fever, night
sweats, malaise, weight loss). Clostridium dicile is commonly present in symptomatic patients with IPAA. Other bacterial pathogens
that have been implicated in are-ups of pouchitis include Clos-
tridium perfringens, Campylobacter species, group D streptococci
(enterococci), and hemolytic strains of Escherichia coli. Case series of
cytomegalovirus infection in immunocompetent patients with pelvic pouches have been reported. Opportunistic infection with fungi
(such as Candida albicans) has also been encountered in patients
with chronic antibiotic-refractory pouchitis (CARP) aer long-term
antibiotic use.
Mucosal Imm
bnormalities of both innate and adaptive mucosal immunities have
A
been implicated in the pathogenesis of pouchitis. An aberrant tolllike receptor expression pattern has been found in the inamed ileal
pouch, and a greater number of copies of human defensin-5 messenger ribonucleic acid (mRNA) have been described in the inamed or
noninamed pouches than in the normal terminal ileum. A greater
number of tissue mRNA copies of Paneth cell human defensin–5 and
gut epithelium–produced β defensins were also found in both UC
and familial adenomatous polyposis pouches. As in persons with
IBD, mucosal adaptive immunity has been extensively studied in persons with pouchitis, with most literature from 1990s. e production
of inammatory mediators is increased, including proinammatory
cytokines, cell adhesion molecules, and vascular endothelial growth
factor. Clinically, patients with antibiotic-refractory pouchitis oen
have other immune-mediated disorders, such as primary sclerosing cholangitis (PSC), autoimmune diseases, and autoinammatory
disorders. It appears that the B cell system may also play a role in
the pathogenesis of CARP, which is typied by the presence of an
excessive number of immunoglobulin (Ig)G4-expressing plasma
cells in the lamina propria of pouch mucosa and/or an elevated level
of serum IgG4. e latter condition is now labeled IgG4-associated
pouchitis.
e pathogenesis of pouchitis is complicated. In addition to the
bacterial and immunologic theories, genetic, mechanical (such as
ischemia), and luminal factors (such as the use of nonsteroidal antiinammatory drugs [NSAIDs]) contribute to the disease initiation,
are-ups, and progression.
unity
The Micr
ultiple layers of evidence support the role of the microbiome in the
M
development of pouchitis. For example, the manipulation of microora with probiotic or antibiotic agents in patients with pouchitis is
oen benecial. Although most acute episodes of pouchitis appear
obiome
DIA
GNOSIS
P
ouchitis is diagnosed on the basis of a combination of typical symptoms and endoscopic and histologic ndings. Diagnosis based on
symptoms alone is dicult. Patients with pouchitis can present with
201
202
Pouchitis
and Functional
comPlic
ations oF the Pelvic Pouch
creased stool frequency, urgency, incomplete evacuation, incon-
in
tinence, increased nighttime seepage, and abdominal or perianal
discomfort. ey oen have a general malaise, but none of these
symptoms is specic for a diagnosis of pouchitis. Furthermore, the
severity of symptoms does not necessarily correlate with the degree
of endoscopic or histologic inammation of the pouch. erefore, a
combined assessment of symptoms with endoscopic and histologic
features is needed for a reliable diagnosis.
Pouchoscopy provides information on type, severity, and distribution of mucosal inammation and detects structural abnormalities of the ileal pouch, such as stricture, sinus, and stula. Mucosal
healing as assessed with endoscopy is a target for medical therapy.
In patients with a high risk for the development of dysplasia, such
as those with a preoperative diagnosis of colonic or rectal neoplasia,
concurrent PSC, and chronic pouchitis or cutis, routine surveillance pouchoscopy with biopsies should be performed.
Histology has a limited role in grading degree of pouch inammation. However, it can provide valid information on special features,
such as the presence of granulomas, viral inclusion bodies, pyloric
gland metaplasia, neoplasia, ischemia or prolapse, and IgG4-associated pouchitis.
ories of Pouchitis
Categ
e term “pouchitis” refers to a disease spectrum, ranging from acute
antibiotic-responsive pouchitis to CARP. Pouchitis can be categorized on the basis of its likely cause, duration, activity, and response
to medical therapy:
1. Idiopathic (dysbiosis associated) versus secondary (to pathogens,
se of NSAID, concurrent autoimmune disease, and ischemia).
u
cute versus chronic, dened by a cuto of 4 weeks of persis
2. A
ent symptoms.
t
nfrequent episodes versus relapsing versus continuous pouch
3. I
is.
it
4. R
esponsive versus refractory to antibiotic therapy (antibiotic
r
esponsive, antibiotic dependent, and antibiotic refractory).
TREA
TMENT
lthough initial acute episodes of pouchitis may be treated empiri-
A
cally with oral antibiotics, pouchoscopy is preferred to conrm the
diagnosis, classify the disease, and guide therapy. For patients with
secondary pouchitis, the evaluation and adjustment of triggering factors is important. For example, patients should be advised to avoid
NSAIDs and possibly estrogen replacement therapy. Superimposed
infection of C. dicile should be periodically excluded, especially in
patients with pouchitis that does not respond to routine antibiotic
(ciprooxacin or metronidazole) therapy.
Antibiotics are the mainstay of treatment of acute pouchitis, with
the rst-line therapy consisting of metronidazole (15 to 20 mg/kg/day)
or ciprooxacin (1000 mg/day) for 14 days. Combined therapy with
ciprooxacin (1000 mg/day) and metronidazole (1000 mg/day) for 28
days may be used for diuse pouchitis with backwash ileitis. Treatment
with other antibiotics has been reported in open-label trials, including
rifaximin, tetracycline, clarithromycin, amoxicillin/clavulanic acid, and
doxycycline.
Patients who have antibiotic-responsive pouchitis may experience frequent relapses and need maintenance therapy. ese patients
are classied as having antibiotic-dependent pouchitis. Randomized controlled trials showed ecacy of a probiotic agent (VSL#3) in
maintaining antibiotic-induced remission in patients with relapsing
pouchitis. However, subsequent open-label trials failed to reproduce these results. Other options for antibiotic-dependent pouchitis
include a long-term, low-dose antibiotic or antiinammatory therapy
using agents such as rifaximin, ciprooxacin, or mesalamine.
cute, antibiotic-responsive pouchitis may evolve into CARP. e
A
disease course of CARP may mimic that of IBD, and the management
of CARP has been challenging. Factors that may be associated with
refractory disease include NSAID use, ischemia, pouch structural
abnormalities, C. dicile and cytomegalovirus infection, concurrent
Crohn disease of the pouch, and cutis. CARP may be a part of systemic autoimmune or autoinammatory disorders.
Fecal culture and sensitivity testing may help identify eective antibiotic agents, but if these are negative treatment options for CARP, a
prolonged course (≥4 weeks) of combined antibiotic therapy may be
initiated, such as a combination of ciprooxacin (1000 mg/day) with
rifaximin (2000 to 2200 mg/day), metronidazole (1000 mg/day) or
tinidazole (1000 to 1500 mg/day). Mesalamine, corticosteroids, immunosuppressive agents, or even anti–tumor necrosis factor biologics
have been used to treat CARP. Oral budesonide (9 mg/day) may be
eective in induction and maintenance therapy in patients with PSCassociated pouchitis/enteritis (Gosselink etal) or IgG4-associated pouchitis. Oral budesonide or a small dose of mercaptopurine (50 mg/day)
may be helpful in patients with CARP who have concurrent PSC, autoimmune, or autoinammatory disorders.
IRRIT
ABLE POUCH SYNDROME
I
rritable bowel syndrome (IBS), a common cause of abdominal discomfort and erratic bowel habits, usually aects the colon. However,
IBS can also occur in patients with ileal pouches or stomas, and the
term “irritable pouch syndrome” (IPS) has been coined. Patients with
IPS present with diarrhea, urgency, and abdominal or pelvic pain in
the absence of endoscopic and histologic inammation. IPS is the
most common functional disorder of the ileal pouch, and patients
with IPS have signicantly compromised quality of life scores, similar
to those associated with inammatory complications such as pouchi-
tis, Crohn disease of the pouch, and cutis.
-
e cause and pathogenesis of IPS are not clear. It is likely that
psychosocial factors, abnormal motor and sensory function of the
gut, and proximal small bowel bacterial overgrowth (with the loss
of the ileocecal valve aer the surgery) play important roles. Regular
use of antidepressants or antianxiety medicines is associated with an
increased risk of IPS. IBS, the counterpart of IPS in patients with
an intact gastrointestinal tract, has been consistently associated with
visceral hypersensitivity and dysmotility of the intestine, and my colleagues and I have noted similar hypersensitivity in patients with IPS.
e causes of the visceral hypersensitivity are not known. In addition
to psychosocial factors, enterochroman cell hyperplasia or mast
cell hyperplasia may play a role. On the other hand, serum serotonin
levels are the same as those in patients with normal pouches. Mucosal
expression of proinammatory mediators was increased in patients
with IPS and pouchitis, suggesting that submicroscopic inammation may contribute to the development of IPS.
Currently, IPS is diagnosis of exclusion. Despite the dramatic
dierence in urgency, gas, and pain between patients with IPS and
control subjects, the barostat has remained a research tool. Stool
inammatory markers such as lactoferrin are useful for dierentiating pouchitis from normal pouches and IPS. However, serum
inammatory markers such as C-reactive protein have a limited
role in separating functional from inammatory complications of
the pouch. e absence of inammation of the aerent limb, pouch
body, or anal transitional zone (ATZ) in patients with the symptoms
is a prerequisite for the diagnosis of IPS. Other confounding factors,
such proximal small bowel bacterial overgrowth or celiac disease,
should be excluded before making a diagnosis of IPS.
IPS can be managed in a similar fashion to IBS. e popular low
FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet for IBS may be benecial for patients
with IPS or for patients with a pouch in general because all those
patients should have a certain degree of proximal small bowel bacterial overgrowth. e treatment of IPS otherwise has been empiric.
T
reatment options include behavioral therapy, antispasmodic agents,
antidepressants, antianxiety agents, and topical agents, including belladonna-opium suppositories.
O
THER FUNCTIONAL DISORDERS
yssynergic defecation is another common functional disorder of
D
the pelvic pouch. Dyschezia can result from functional or inammatory disorders of the pouch outlet, such as an anal stenosis or paradoxical contraction of the pelvic oor (puborectalis). Persons with
paradoxical contraction of the puborectalis benet the most from
pelvic biofeedback therapy. A restriction of the stool entering the
pouch may occur as a result of the so-called aerent loop syndrome,
which means some sort of partial obstruction of the aerent loop of
ileum by twisting, an adhesion, kinking, or a tumor. Pouchoscopy
provides some clue about the presence of an obstructed aerent loop.
Because medical and surgical treatment of pouch prolapse has been
challenging, the rst-line therapy for patients with concurrent paradoxical contraction and pouch prolapse may be biofeedback therapy.
Less common functional disorders of the pouch include pouchalgia fugax and functional megapouch. Patients with pouchalgia fugax
may have a sawtooth anal resting pressure tracing and may have
concurrent anal ssure. Topical agents, such as nitroglycerin ointment and botulinum toxin, may be helpful. Patients with a functional
megapouch should undergo surgery.
CONCLUSIONS
Pouchitis is the most common long-term complication aer restorative
proctocolectomy and presents as a spectrum of disease processes with
various pathogenic pathways, clinical phenotypes, and prognoses. Treatment of pouchitis should be based on its cause. Functional complications
of the pelvic pouch, especially IPS, are common. Tricyclic antidepressants are the rst-line pharmacotherapeutic agents for patients with IPS.
Patients with dicult defecation should be evaluated with anorectal
physiology testing. Pouch endoscopy is the most valuable tool for diagnosis of inammatory and functional disorders of the pouch.
COLON
S
g g e
u
S t
azio VW, Ziv Y, Church JM, etal. Ileal pouch-anal anastomosis complica-
F
tions and function in 1005 patients. Ann Surg. 1995;222:120–127.
Gionchetti P, Rizzello F, Helwig U, etal. Prophylaxis of pouchitis onset with
probiotic therapy: a double-blind placebo controlled trial. Gastroenterol-
ogy. 2003;124:1202–1209.
Gionchetti P, Rizzello F, Morselli C, etal. High-dose probiotics for the treat-
ment of active pouchitis. Dis Colon Rectum. 2007;50:2075–2082. discus-
sion 2082–2084.
Gosselink MP, Schouten WR, van Lieshout LM, etal. Eradication of patho-
genic bacteria and restoration of normal pouch ora: comparison of metronidazole and ciprooxacin in the treatment of pouchitis. Dis Colon Rec-
tum. 2004;47:1519–1525.
Kariv R, Remzi FH, Lian L, etal. Preoperative colorectal neoplasia increases
the risk for pouch neoplasia in patients with restorative proctocolectomy.
Gastroenterology. 2010;139:806–812.
Khanna R, Li Y, Schroeder T, etal. Manometric evaluation of evacuatory di-
culty (dyschezia) in ileal pouch patients. Inamm Bowel Dis. 2013;19:569–
575.
Komanduri S, Gillevet PM, Sikaroodi M, et al. Dysbiosis in pouchitis: evi-
dence of unique microoral patterns in pouch inammation. Clin Gastro-
enterol Hepatol. 2007;5:352–360.
Mimura T, Rizzello F, Helwig U, etal. Once daily high dose probiotic therapy
(VSL#3®) for maintaining remission in recurrent or refractory pouchitis.
Gut. 2004;53:108–114.
Nasmyth DG, Godwin PGR, Dixon MF, etal. Ileal ecology aer pouch anal
anastomosis or ileostomy. Gastroenterology. 1989;96:817–824.
Penna C, Dozois R, Tremaine W, etal. Pouchitis after ileal pouch-anal
anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut.
1996;38:234–239.
Sandborn WJ, Tremaine WJ, Batts KP, et al. Pouchitis aer ileal pouch-
anal anastomosis: a pouchitis disease activity index. Mayo Clin Proc.
1994;69:409–415.
Shen B, Achkar J-P, Lashner BA, et al. A randomized trial of ciprooxa-
cin and metronidazole in treating acute pouchitis. Inamm Bowel Dis.
2001;7:301–305.
Shen B, Achkar J-P, Ormsby A, etal. Endoscopic and histologic evaluations
together with symptom assessment are required to diagnose pouchitis.
Gastroenterology. 2001;121:261–267.
Shen B, Plesec TP, Remer E, etal. Asymmetric inammation of ileal pouch: a
sign for ischemic pouchitis? Inamm Bowel Dis. 2010;16:836–846.
e d
R
a d i n g
e
203
C
I
J
on Worsey and Victor W. Fazio
INTR
ODUCTION
e continent ileostomy has an interesting history. It began as a
revolutionary concept and technique, only to fall out of routine use
because of technical issues and ultimately a better alternative: the ileal
pouch–anal anastomosis (IPAA). Indications for a continent ileostomy still exist, although the operation is now rarely performed. It
has undergone multiple modications, is technically demanding,
and is associated with a relatively high need for revisions. However,
patients with a continent ileostomy oen go to great lengths not to
lose their pouch, even if this means traveling long distances to one
of the ever-dwindling number of surgeons skilled in pouch management and being willing to undergo major revisions and repairs.
In this chapter we will discuss the evolution of the continent ileostomy, the technique as it currently stands, indications, contraindications, and common complications and their management. We will
also outline the management of urgent problems for persons unfamiliar with these pouches.
EV
OLUTION OF THE CONTINENT
ILEOSTOMY
In 1952, Brian Brooke revolutionized the end ileostomy by simply
everting the mucosa of the ileum and suturing it to the skin. is
technique resolved the major and at times debilitating problem
of “ileostomy dysfunction” caused by ileal serositis. Despite this
advance, there was still a strong incentive to nd an alternative to
the end ileostomy, which entails a major change in lifestyle and
body image and is dicult for patients to accept. In addition, early
stoma appliances were quite rudimentary and both less comfortable and more prone to fail than they are today. At this time the
discipline of stoma therapy, started by Turnbull and Gill, was still
in its infancy.
During the 1960s, Nils Kock of the University of Goteborg,
Sweden, developed a technique to create a continent intestinal reservoir. He presented this work at the 26th Annual Meeting of the
Central Surgical Association in Chicago, Illinois, on February 21,
1969. Kock described the cases of ve patients in whom he detubularized and recongured the distal ileum to make a low-pressure
U-shaped pouch, a corner of which was opened onto the abdomen (Fig. 40-1). Continence relied upon making “the ileostomy
canal through the abdominal wall narrow and oblique through
the rectus muscle in order to obtain sucient closing of the outlet of the reservoir.” Advantages compared with a conventional
ileostomy included placement of a ush stoma much lower in the
abdomen where it was easy to conceal, without the need to wear
an appliance.
Despite the initial promise of this pouch, it soon became clear
that the continence mechanism was inadequate. Kock modied his
design by adding an eerent limb to the pouch and creating a oneway nipple valve by intussusception of part of the eerent limb into
the pouch (Fig. 40-2). is modication was a great improvement,
but over time it became apparent that the valve was prone to sliding
or slipping. Subsequent modications to stabilize the valve took one
of two approaches: modications of the basic design to better x the
valve, or modications of the pouch design itself to make a valve less
susceptible to slipping.
TECHNIQUES T
O BETTER FIX THE
VALVE
e valve has an inherent tendency to slip because peristalsis pro-
motes undoing of the intussusception. Initially the intussusception
was held in place by sutures passed through both segments of intussuscepted bowel, avoiding the mesentery. Later, the use of a noncutting linear or TX stapler replaced this technique and has proved more
eective. e following additional maneuvers help hold the intussuscepted bowel in place:
•Useofsclerosingagentsonitsserosa
•Scarifyingitsserosawithcauterytocausean
reaction
•Carefullystrippingtheperitoneumfromthemesenteryofthe
owel making up the valve
b
•Debulkingor
•Placingsuturesaroundthefundusofthepouchatthe
the valve to the pouch wall. Initially sutures were used, but the use of
another row of staples, as described by Fazio and Tjandra in 1992, is
most eective.
of a m
•Use
do
ned because it led to stula formation)
e most important modication seems to have been attaching
esh
defa
co
tting
hickmesentery
at
at the exit co
llar
POUCH DESIGN MODIFIC
e rst major modication to the basic Kock design was described
by Barnett in 1987. He constructed an isoperistaltic valve and then
wrapped a segment of bowel contiguous with the pouch around
the exit conduit as it le the pouch (Fig. 40-3). A T pouch was
described by Kaiser in 2002, based on one used by his urology
colleagues. A nonintussuscepted valve mechanism was created by
anchoring and opening an isolated bowel segment into a serosalined trough formed by the base of two adjacent ileal segments that
constitute the pouch (Fig. 40-4). ese pouches have their advocates but do not seem to be any easier to create technically or to
give results superior to the most current modication of the original design.
(e
.g.,tetracyclinepowder)
nduit
(e
in
ective
ammatory
exitco
but a
ATIONS
nduit
ban
-
204
COLON
205
FIGURE 40-1
Cleveland Clinic Center for Medical Art & Photography. Copyright 2009-
sion,
2016. All Rights Reserved.)
FIGURE 40-2
permission,
2009-2016. All Rights Reserved.)
Original K
K
Cleveland Clinic Center for Medical Art & Photography. Copyright
ock U-shaped pouch.
ock pouch with intussuscepted valve.
(Reprinted with permis-
(Reprinted with
FIGURE 40-4
pouch: a new valve design for a continent ileostomy. Dis Colon Rectum.
2002;45:411-415, with permission.)
CURRENT
T pouch. (Fr
om Kaiser AM, Stein JP, Beart RW Jr. T-
INDICATIONS AND
CONTRAINDICATIONS
e most common indication for a continent ileostomy is the need
for a proctocolectomy in someone who is not a candidate for an IPAA
but wishes to avoid a conventional Brooke ileostomy. IPAA may be
impossible either for practical reasons (such as poor anal sphincter
function) or technical reasons (such as lack of pouch reach or a prior
proctocolectomy including the anus). A failed IPAA can also be converted to a continent ileostomy if it can be mobilized from the pelvis
without too much damage.
Obesity is a relative contraindication to a continent ileostomy
because the fatty mesentery causes issues with valve creation and
passage of the exit conduit through the widened abdominal wall is
dicult. Patients need a certain level of dexterity, cognitive function,
and motivation to adequately use and care for the pouch. As with
the IPAA, it should not be performed in a person with co-existing
small bowel Crohn disease, although colonic and anal Crohn disease
may not be a contraindication. Prior loss of a signicant amount of
small bowel is also a relative contraindication because a pouch will
use another 50 to 70 cm of bowel, and if the pouch were to fail and
need to be removed, this loss could be signicant. Finally, the procedure should not be performed by a surgeon who lacks experience in
the management of common complications (Box 40-1).
FIGURE 40-3
printed with permission,
phy. Copyright 2009-2016. All Rights Reserved.)
Barnett modification of the continent ileostom
Cleveland Clinic Center for Medical Art & Photogra-
CURRENT
SURGICAL TECHNIQUE
AND STATUS
ey Surgical Points
K
e key points are an S pouch design with 12- to 15-cm limbs, using
y.
(Re-
another 12 cm for the creation of the valve and at least 6 cm for the exit
conduit (more for a thicker abdominal wall; Fig. 40-5). Valve preparation includes stripping of the peritoneum over the mesentery, defatting of a bulky mesentery, and scarication of the serosa with cautery.
e valve is held by two or three rows of staples from a TX 60-mm
206
Continent ileost
omy
BO
X 40-1:
ileostom
Most common complications of the continent
y
• Stomastenosis
•V
alveslippageor
•P
arastomalhernia
•P
ouchitis
stula
•Fi
ohn
•Cr
•S
12–15cm
seaseofthe
di
carandstenosisatthe
7cm
12cm
des
usception
inowt
lvetip
va
ractorpouch
II
I
III
FIGURE 40-6
sion,
Cleveland Clinic Center for Medical Art & Photography. Copyright 2009-
2016. All Rights Reserved.)
Fixation of valv
e to pouch wall.
(Reprinted with permis-
FIGURE 40-5 Bo
permission,
2009-2016. All Rights Reserved.)
s
tapler, with ve to seven staples in the crotch of the stapler removed,
wel measurement and S-pouch design.
Cleveland Clinic Center for Medical Art & Photography. Copyright
(Reprinted with
because if the staples cross the tip of the valve, they can both stent it
open and predispose to ischemia. An additional row of staples across
the valve includes the anterior pouch wall to further hold the valve in
the pouch (Fig. 40-6). Sutures are placed between the exit conduit and
fundus of the pouch to further reduce valve slippage. An oval stomal
aperture can be placed much lower in the abdomen than that for a
conventional ileostomy, oen just above the pubic hairline. Sutures
are placed from the pouch to the undersurface of the abdominal wall
to securely hold it in place (Fig. 40-7), and the pouch typically tends
to lie in the pelvis. If the pouch construction is being performed at
the end of a long and dicult proctocolectomy, the small bowel may
become edematous and intussusception of the valve quite dicult. In
these cases, performing the abdominal colectomy and then making
the pouch before the small bowel becomes edematous is an option,
with the proctectomy completed aer this procedure.
Good postoperative care is critical. Initially the pouch is continuously drained for 3 weeks, and is ushed with 60 mL of water every 8
hours. Aer 3 weeks, the drainage tube is removed and the pouch is
intubated every 2 hours. Increasing the interval between pouch intubations over a 6-week interval allows the pouch to stretch from its
original small size, and intubation can be on demand.
ypical Pouch Function
T
M
ost patients wear a small pad or dressing over the stoma aperture because a small amount of mucus is always present. Emptying
the pouch on demand is typically performed three to four times a
day using a specially designed (Waters) catheter and ushing with
FIGURE 40-7
Cleveland Clinic Center for Medical Art & Photography. Copyright 2009-2016.
All Rights Reserved.)
Securing the pouch in place. (Reprinted with permission,
t
ap water. As with an ileostomy, certain foods that are not readily
digested and thick stool can be dicult to empty via the catheter.
Patients oen use grape or prune juice to help with consistency, but
most have a relatively normal diet.
COLON
207
COMPLIC
ATIONS OF A CONTINENT
ILEOSTOMY
erioperative Complications
P
Immediate issues with sepsis and bleeding may occur that are common to all extensive surgeries, but because the pouch is continuously
drained and irrigated, issues with leakage or dehiscence are uncommon. Bowel function returns surprisingly quickly.
Placement of multiple staple lines along the valve may make the
valve relatively ischemic, and during defatting of the mesentery, it is
important that the mesenteric vessels be preserved. An ischemic valve
may be prone to stenosis, especially at the mucocutaneous junction.
y Complications
Earl
e most common early complication is stricturing of the mucocu-
taneous junction of the stoma. is complication is easily managed
with excision of the scar and mobilization and advancement of the
outow tract. However, care must be taken not to damage the blood
supply of the bowel, and each repeat procedure shortens the xed and
nite length of the outow tract.
Late Complications
Valve Slippage
Despite the previously described modications, valve slippage
remains a long-term problem and may be suspected in cases of progressive diculty with intubation, incontinence, or prolapse at the
stoma. Acute valve slippage angulates the valve, prevents intubation,
and is in eect an acute bowel obstruction. Pouchoscopy will show
loss of xation of the valve to the pouch wall. Sometimes repair may
be accomplished at laparotomy by simply opening the pouch, pulling
the valve back in to the pouch, and reattaching it to the pouch wall
with the stapler. If the existing valve cannot be salvaged, the pouch
needs to be taken down from the abdominal wall and the exit conduit
excised (Fig. 40-8, A). A new valve and outow tract are then made
from about 20 cm of the inow tract by intussuscepting it as for a
primary procedure, and the bowel is then divided proximal to this
(Fig. 40-8, B). e pouch is then rotated to bring out the new outow
tract at the existing exit site (Fig. 40-8, C), and the divided proximal
bowel is then anastomosed to the pouch, which requires careful division of the mesentery (Fig. 40-8, D). is technique is called a “pouch
rotation” and is in essence how an IPAA is converted to a continent
ileostomy. e aerent limb is used for the valve/outow tract.
AB
CD
FIGURE 40-8
“turnaround procedure.” Currently, stapling rather than suturing
tract:
is used in this procedure. (From Kock NG. Present status of the continent
ileostomy: surgical revision of the malfunctioning ileostomy. Dis Colon Rectum. 1976;19:200-206, with permission.)
ulcerative colitis may subsequently experience a complication attributable to Crohn disease. Inammation and narrowing of the bowel
entering the pouch is a common manifestation, and initially it is
treated medically. If medical treatment is not eective, surgery may
be needed, and because removal of this segment of bowel may disrupt
the pouch blood supply, a simple bypass of the more proximal bowel
into the pouch can be performed. Because recurrent Crohn disease
here is common, prophylactic medical treatment should be considered. Fistulae from the pouch and disease within the pouch are more
dicult to treat if they are nonresponsive to medical therapy and can
lead to pouch loss.
Pouchitis
Pouchitis may occur in the continent ileostomy, although probably
with less frequency than in the pelvic pouch. Pouchitis is diagnosed
by pouchoscopy with a biopsy and is managed with antibiotics (metronidazole or ciprooxacin).
Valve Stenosis
A scar at the tip of the nipple valve is a late complication that hinders catheter insertion; sometimes a exible or rigid scope can be
used to carefully dilate this stenosis. Occasionally it will need to be
dilated at laparotomy by opening the pouch or a new valve will need
to be made. Finally, because the skin around the stoma is oen moist
from mucus, pseudoverrucous change with whitening, thickening,
and overgrowth of the skin is occasionally seen. Very rarely it may
encroach upon the stomal aperture and require careful excision.
Steps in
volved in the creation of a new valve and outlet
Parastomal Hernia
A parastomal hernia may present as incontinence or dicult intubation. Because primary repair has high rates of recurrence, mesh
is typically used as an onlay aer the defect is repaired. Because of
infection risk, a biologic mesh is typically used, but the durability of
most of these repairs has been disappointing.
Crohn Disease
To quote the senior author (VF), “ere is nothing like a pouch to
bring out the Crohn’s in a patient,” and a patient thought to have had
Pouch Excision
Occasionally a pouch cannot be salvaged and must be excised.
is procedure can be exceptionally challenging because oen the
patient has undergone multiple prior procedures and the pouch
itself can lie almost anywhere, sometimes deep in the pelvis. e key
is to mobilize the pouch outow tract early and then mobilize the
remainder of the pouch. Remember it is an S pouch with three limbs
and thus three layers of mesentery. e inow tract over time may
become quite dilated, which sometimes makes creation of a new
pouch almost impossible and indeed leads to a challenging ileostomy creation.
208
Continent ileost
omy
WHA
T TO DO WHEN A PATIENT
PRESENTS ACUTELY WITH THE
INABILITY TO INTUBATE HIS OR HER
POUCH
e most common urgent presentation to an oce or emergency
department is the inability to intubate the pouch as a result of a hernia or valve slippage, with increasing abdominal pain and pressure.
e surgeon or gastroenterologist who is called to see the patient, and
who may never before have seen a continent ileostomy, should take
the following steps:
1. Listen to the patient, who likely has been doing this a long time
nd may know more about it than you do.
a
ive patients a little pain medication to help them relax and
2. G
ave them try again. Sometimes patients intubate the pouch
h
while sitting or standing.
3. I
f the patient is unsuccessful, have him or her lie at and relax
a
nd try to gently insert the tube yourself. Ask the patient which
direction the catheter usually takes. Slow, steady pressure is the
key. If the patient has a lot of pain or if you meet any resistance,
stop. Additional pain or anxiolytic medication may help.
repare either the small-diameter (pediatric) rigid sigmoido
4. P
cope or exible videoscope (usually a pediatric gastroscope)
s
and get a large basin with wall suction ready. e advantage
of using the pediatric gastroscope is that a Waters tube can be
inserted over the endoscope and then advanced into the pouch
once the valve has been intubated (see Suggested Reading).
5. U
nder direct vision, with gentle and limited insuation, follow
t
he outow tract to the pouch. If intubation is unsuccessful, a
general anesthetic will be needed.
f using the rigid scope, take great care in removing the obtu
6. I
7. On
8.
9. I
tor once it is in the pouch because the pouch contents are
ra
usually under pressure.
ce decompressed, the drainage tube is secured in the pouch
a
nd attached to a leg bag.
e patient can now speak to the surgeon who manages the
p
ouch.
f the valve slipped, splinting the valve for 3 weeks may prevent
further slippage. e only other alternative is a valve revision.
CONCLUSIONS
C
urrently the continent ileostomy is performed and revised by a
small group of enthusiasts. e keys to success are:
areful attention to technique and an experienced surgeon
1. C
2. U
se of a technique modied to minimize valve slippage and
t
he other common complications
3. A r
4. Careful patient selection:
tinue to be a valuable and relevant surgical procedure rather than a
historical curiosity.
-
S
arnett WO. New approaches for continent ostomy construction. J Miss State
B
Church JM, Fazio VW, Lavery IC. e role of beroptic endoscopy in the
Fazio VW, Tjandra JJ. Technique for nipple valve xation in to prevent valve
Kaiser AM, Stein JP, Beart Jr RW. T-pouch: a new valve design for a continent
-
Kock NG. Intra-abdominal ‘reservoir’ in patients with permanent ileostomy.
Lian L, Fazio VF, Remzi FH, et al. Outcomes for patients undergoing con-
egimented postoperative intubation routine to minimize
co
mplications and enlarge the pouch
•Choosepatientswhoaremotivated,
exp
ectations
•Avoid
cr
eatingthe
co
ntinentileostomy
dext
erous,andrealistic
inp
atientsforwhom
technical failure is likely (e.g., obese patients)
•Makesurepatients
f revision or repair
o
f these principles are followed, the continent ileostomy will con-
I
g g e
u
Med Assoc. 1987;28:1–3.
management of the continent ileostomy. Gastrointest Endosc. 1987;33(3):
203–209.
slippage in continent ileostomy. Dis Colon Rectum. 1992;35:1177–1179.
ileostomy. Dis Colon Rectum. 2002;45:411–415.
Preliminary observations on a procedure resulting in fecal continence in
ve ileostomy patients. Arch Surg. 1969;99:223–231.
tinent ileostomy aer a failed ileal pouch-anal anastomosis. Dis Colon
R
e d
S t
ectum
. 2009;52:1409–1416.
R
un
a d i n g
e
derstandand
acceptthehighli
in
kelihood
P
U
W
J
esse Moore and Neil Hyman
INTR
ODUCTION
E
xcision of the rectum via a combined abdominal and perineal
approach (i.e., an abdominoperineal resection [APR]) has been a
time-honored technique for the management of rectal cancer and
inammatory bowel disease (IBD). However, achieving prompt and
satisfactory healing of the perineum aer such an approach is still a
challenge. A wound that has not healed by 6 months aer the surgery is considered an unhealed perineal wound (UPW), even though
many such wounds will eventually heal by 1 year. e rate of failed
perineal wound healing varies greatly in the literature; however, a
reasonable estimate suggests that it occurs 20% to 30% of the time.
Despite changes in practice that have minimized the number of
patients undergoing an APR, some circumstances may lead to this
operation secondarily.
SPECIAL SITU
ATIONS LEADING
TO AN UNHEALED PERINEAL
WOUND
1. F
ailed restorative proctectomy: e focus on sphincter-preserv
in
g approaches for both anorectal cancer and IBD has decreased
the attention given to the UPW or persistent perineal sinus.
However, sometimes complications of these sphincter-saving
procedures may require a subsequent proctectomy. At this time,
avoiding the morbidity of an unhealed perineal wound may be
more dicult.
ailed ileal-anal pouch: Although ileal pouch–anal anastomosis
2. F
h
as largely replaced total proctocolectomy with ileostomy as the
surgical treatment for ulcerative colitis, pouch failure occurs in
approximately 5% to 10% of cases and sometimes requires abdominoperineal excision of the pelvic pouch. Pouch excision has
been associated with a risk for UPW of 40% and 10% at 6 and 12
months, respectively.
ecurrent anal and rectal cancer: Combined modality chemo
3. R
ation has supplanted surgery as the primary treatment for
radi
squamous cell carcinoma of the anal canal, yet when recurrent
disease is diagnosed, salvage APR is generally performed in an
irradiated eld. Similarly, recurrent rectal cancer aer low anterior resection may be approached with aggressive multivisceral
resections including proctectomy, oen combined with preoperative and/or intraoperative radiation. Challenges of reconstruction in these circumstances may be formidable and lead to
considerable morbidity.
R is likely to be a continuing problem facing colorectal sur-
AP
geons. Prevention and management of this complication continue to
be important topics and are the subjects of this chapter.
C
AUSES
T
echnical, patient-related, or disease-related factors may lead to a
failure of perineal wounds to heal.
echnical Factors
T
er the rectum is excised, a large pelvic cavity is created, and ll-
A
ing this space with healthy, well-vascularized so tissue is important
in promoting primary healing. Posterior migration of the remaining genitourinary structures and descent of the peritoneal oor help
diminish this cavity, but the bony walls laterally and posteriorly tend
to prevent it from closing completely.
Excessive bleeding with formation of a hematoma adversely
aects postoperative healing, especially if contamination with stool
occurs. e resulting pelvic collection may result in a rigid, brotic
cavity that will heal very slowly if at all. Nonabsorbable sutures may
serve as foreign bodies and impair long-term healing.
-
Patient-Specific Factors
Malnutrition, diabetes, or obesity may contribute to poor healing,
and the underlying indication for proctectomy also clearly aects
the likelihood of an unhealed perineal wound. UPW is most likely
to occur aer a proctectomy for Crohn disease or in the setting of
intraoperative radiation and neoadjuvant radiation, whereas patients
undergoing a proctectomy for ulcerative colitis or rectal cancer typically have much lower rates of perineal wound breakdown.
Crohn Disease
Patients with Crohn disease are particularly prone to UPW aer
proctectomy for several reasons. Crohn disease may be present in
the perineal skin itself, which leads to failure of healing at the skin
level. In addition, considerable perirectal brosis is oen present as
a result of transmural inammation and/or stulization, making a
proctectomy technically more dicult and predisposing to inadvertent rectal perforation or residual rectal mucosa, both of which are
triggers for a UPW. Chronic use of immunomodulators and/or biologic agents, protein-calorie malnutrition, inadequately controlled
systemic inammation, and local sepsis are also factors predisposing
to poor wound healing.
Radiation
In many studies, pelvic irradiation appears to increase the risk of
UPW, presumably because of the ischemia and brosis that follow
209
210
Unhealed
Perineal Wo
Und
ts use. e risks associated with radiation may be exacerbated by
i
concomitant chemotherapy.
PREVENTION
eoperative
Pr
rior to performing a proctectomy, nutritional status and glucose
P
control should be optimized, the patient who smokes should be
encouraged to stop smoking, and steroid, biologic agent, and immunomodulator usage should be planned to cover the surgery while
minimizing risk.
Perianal sepsis has been associated with poor perineal wound healing aer proctectomy, particularly in patients with a “watering can”
perineum. In one study of such patients, the rate of UPW was 46%,
and other investigators have reported higher rates. e best approach
to patients with symptomatic perianal Crohn disease remains controversial. Options include preliminary examination aer induction of
anesthesia with debridement, drainage of abscesses, and placement of
setons (Fig. 41-1), fecal diversion with a loop ileostomy, or an initial
subtotal colectomy with an ileostomy. A near-total proctocolectomy
with an ultra-low Hartmann pouch can excise almost all the rectum
and avoid a perineal wound. If “perineal Crohn disease” is present,
biologic agents are likely to improve the tissues and reduce the risks
of chronic wounds. ey may need to be continued postoperatively.
Each case should be individualized based on an understanding
of the patient’s symptoms, goals, and concerns regarding treatment
and outcomes.
Intraoperativ
A thorough knowledge of pelvic anatomy and familiarity with tissue
planes are invaluable in performing a dicult proctectomy. Meticulous hemostasis is critical to avoid a postoperative pelvic hematoma.
Closed suction drains are appropriate in the immediate postoperative period but should be removed as soon as possible to minimize
secondary sepsis.
e
In any patient with obliterated pelvic tissue planes, inadvertent entry
into the rectum with pelvic contamination is possible. Should this happen, the pelvis should be copiously irrigated and closed suction drains
should be placed. Islands of rectal mucosa should be sought and eradicated to avoid long-term problems with mucus production.
A low Hartmann procedure has been advocated for patients with
complicated perianal manifestations of Crohn disease. is operation
has the advantage of removing almost all of the diseased colon and
rectum while avoiding perineal dissection in a septic eld. However,
many patients who undergo a low Hartmann procedure will later
require excision of the anus and distal rectum because of persistent
drainage, recurrent perianal sepsis, and discomfort. e keys to
avoiding this situation are preoperative control of sepsis and transection of the rectum as low as possible.
Intersphincteric proctectomy is our preferred option when wide
oncologic margins are not required. An intersphincteric proctectomy
creates a smaller perineal wound (Fig. 41-2) and preserves the external sphincters and levator ani muscles, creating a well-vascularized
barrier between the perineum and pelvis. Working in the relatively
avascular intersphincteric plane decreases the risk of hematoma formation and excessive blood loss. e combination of intersphincteric
proctectomy, secure closure of the pelvic oor, and debridement and
drainage of perianal sepsis is ideal for patients with perineal sepsis.
It is usually followed by healing of skin and subcutaneous tissues by
secondary intention. e empty pelvis above the pelvic oor can be
lled with a well-vascularized omental pedicle ap or the small bowel.
Reconstruction of the Perineum with a Flap
Patients requiring a proctectomy for recurrent/persistent anal cancer
aer chemoradiation, those who receive intraoperative radiation for
recurrent rectal cancer, and those who require a full pelvic exenteration
for advanced malignancy are candidates for a primary myocutaneous
or muscle ap. Gracilis and vertical rectus abdominis myocutaneous
(VRAM) aps are the ones most commonly used. Other aps include
the posterior thigh, gluteus, and latissimus dorsi free ap.
e gracilis ap can be constructed with or without an accompanying skin paddle. In women who require excision of the posterior
FIGURE 41-1 A “watering can” perineum after superficial debride-
ment and placement of setons f
or control of sepsis.
FIGURE 41-2 A healed perineal w
octectomy.
pr
ound after an intersphincteric